Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 480 - HOME AND COMMUNITY-BASED SERVICES
Chapter 3 - PARTICIPANT ACCESS AND REQUIREMENTS
Section 480-3-003 - PARTICIPANT ELIGIBILITY
Universal Citation: 480 NE Admin Rules and Regs ch 3 ยง 003
Current through September 17, 2024
003.01 ELIGIBILITY CRITERIA. Participants eligible for Waiver services must:
(A) Be eligible for Nebraska
Medicaid in a category authorized to receive services from the Waiver under
which services are being requested;
(B) Have conditions which place the
individual in the target populations identified in the Waiver under which
services are being requested;
(C)
Have participated in an assessment, including any reassessments, with a
services coordinator in accordance with this chapter;
(D) Meet the nursing facility level of care
criteria outlined in Title 471 Nebraska Administrative Code (NAC);
(E) Be determined that meeting the care needs
of the participant would not result in Nebraska violating the cost
effectiveness requirements outlined in this chapter;
(F) Receive an explanation of nursing
facility services and Waiver services and choose to receive Waiver services;
and
(G) Use Waiver services at
least every 60 days. Exceptions apply for cases that are Assistive Technology
Supports (ATS) or Home and Vehicle Modification (H/VM) requests only, or in the
event there is a delay in enrollment of the preferred provider.
003.02 ELIGIBILITY DETERMINATION. All participants must have an eligibility determination in order to be able to access Waiver services. Eligibility determinations include:
003.02(A)
ASSESSMENT. An in-person assessment will be completed
by the services coordinator, participant, and legal guardian when applicable. A
child must be reassessed as an adult when they reach age 18. The following
steps are included within the intake process:
(i) A referral for services will be accepted
from any source;
(ii) Each
participant must be determined Medicaid eligible, or under consideration for
Medicaid eligibility; and
(iii) The
services coordinator will contact the participant and schedule an in-person
meeting to evaluate nursing facility level of care, within 14 calendar days of
the referral date. Assessments are scheduled at a time and date convenient to
the participant and their guardian, when applicable this may result in
scheduling outside the 14 calendar day window.
003.02(B)
PRIORITY CRITERIA FOR
ASSESSMENT. If a statewide waiting list is required due to limited
Waiver capacity, the Department may determine that an individual qualifies for
a priority placement into an available Waiver opening. The Department retains
sole discretion to determine the applicability of criteria and the need for
prioritization of an assessment. Criteria to be considered to expedite the
assessment include, but are not limited to:
(i) Needs that are so severe the health and
welfare of the participant are jeopardized, but the needs could safely be met
with immediate Waiver services;
(ii) Family or caregivers are in a crisis
situation;
(iii) No informal
support network is available to meet identified needs;
(iv) Inappropriate out-of-home placement is
being planned;
(v) No other program
is available to meet the needs identified in the referral;
(vi) Support services are required to allow
the participant to return home such as, a Medicaid-eligible recipient is ready
to be discharged from a hospital or nursing facility; and
(vii) A participant with an identified Waiver
service need of Assistive Technology Supports or Home and Vehicle Modifications
(ATS, H/VM) lacks access to resources to meet these specific needs AND Waiver
eligibility is the only method of addressing the identified needs.
003.02(C)
ONGOING
ASSESSMENTS. An in-person re-evaluation of nursing facility level
of care and needs assessment are required at least annually or any time that
there is a change in a participant's condition in order to ensure the
participant continues to meet criteria identified in 471 NAC 12-000 to be
eligible for Waiver services.
003.02(D)
DETERMINATION OF
NURSING FACILITY LEVEL OF CARE. The Department will determine
nursing facility level of care in accordance with Title 471 NAC.
003.02(E)
PERSON-CENTERED PLAN
(PCP). A Person-Centered Plan (PCP) must be developed for each
participant. For children aged 0-3 years old that are also utilizing early
intervention services, the Individual Family Service Plan (IFSP) is the
person-centered plan (PCP). The service planning process should be directed by
the participant and any applicable representative. Steps included in the
person-centered planning process are:
(i)
PLAN DEVELOPMENT. The participant, together with the services coordinator,
develops a person-centered plan (PCP) based upon assessment results of the
potential participant's strengths, needs, priorities, preferences and
resources.
(ii) PLAN REQUIREMENTS.
The person-centered plan (PCP) must meet the following requirements:
(1) Reflect that the setting in which the
participant resides is chosen by the individual;
(2) Reflect the participant's strengths and
preferences;
(3) Reflect clinical
and support needs;
(4) Include
individually identified goals and desired outcomes;
(5) Reflect the services and supports (paid
and unpaid) that will assist the client to achieve identified goals, and the
providers of services and supports, including informal supports;
(6) Reflect risk factors and measures in
place to minimize them, including individualized back-up plans and
strategies;
(7) Identify the
individual and entity responsible for monitoring the plan;
(8) Document that any modification is
supported by a specific assessed need and justified. The following requirements
must be documented in the person-centered plan (PCP):
(a) Identify a specific and individualized
assessed need;
(b) Document the
positive interventions and supports used prior to any modifications to the
person-centered plan (PCP);
(c)
Document less intrusive methods of meeting the need that have been tried but
did not work;
(d) Include a clear
description of the condition that is directly proportionate to the specific
assessed need;
(e) Include a
regular collection and review of data to measure the ongoing effectiveness of
the modification;
(f) Include
established time limits for periodic reviews to determine if the modification
is still necessary or can be terminated;
(g) Include informed consent of the
participant;
(iii)
PLAN
IMPLEMENTATION. The person-centered plan (PCP) must be finalized
and agreed to, with the informed consent of the participant, and the
participant's legal representative when applicable.
Disclaimer: These regulations may not be the most recent version. Nebraska may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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